Basic Information
| Provider Information | |||||||||
| NPI: | 1073918470 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TELECARE MENTAL HEALTH SERVICES OF ARIZONA, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TELECARE SIERRA VISTA ACT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1080 MARINA VILLAGE PARKWAY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ALAMEDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945011078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103377950 | ||||||||
| FaxNumber: | 5103377969 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 N GARDEN AVE | ||||||||
| Address2: | |||||||||
| City: | SIERRA VISTA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856353805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204599929 | ||||||||
| FaxNumber: | 5204598152 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2014 | ||||||||
| LastUpdateDate: | 04/01/2015 | ||||||||
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| AuthorizedOfficialLastName: | LANGFELD | ||||||||
| AuthorizedOfficialFirstName: | MARSHALL | ||||||||
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| AuthorizedOfficialTitleorPosition: | SVP, CFO | ||||||||
| AuthorizedOfficialTelephone: | 5103377950 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | OTC6995 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 987017 | 05 | AZ | MEDICAID |